3 P’S

PERSONAL PROFILE

Name: Aling Nena

Age: 41 years old
Sex: Female
Address: Brgy. Quezon, Solano, Nueva Vizcaya
Birthdate: January 12, 1978
Birthplace: Brgy. Quezon, Solano, Nueva Vizcaya
Civil Status: Married
Nationality: Filipino
Primary Language: Ilocano
Religion: Roman Catholic
Educational Attainment: High School Graduate
Occupation: Restaurant Cashier

Date/Time of Admission: January 20, 2019/ 9:30 AM

Attending Physician: Dr. HB
Admitting Diagnosis: G4P3 (3003) Pregnancy Uterine 32 weeks AOG,Pre eclampsia
Principal Diagnosis: G4P4(4004) Pregnancy Uterine 32 1/7 weeks AOG 2000g
Premature baby boy delivered via LTCS; HELLP Syndrome secondary to Pre eclampsia

Significant Other’s Profile:

Name: Manong Lando
Address: Brgy. Quezon, Solano, Nueva Vizcaya
Educational Attainment: High School Undergraduate

Occupation: Butcher

Relationship to the Patient: Husband

PAST ILLNESS
Aling Nena stated that she experiences minor illnesses such as cough, colds and fever
over the years and that whenever she feels unpleasant, she buys over the counter
medications like Paracetamol and Decolgen. No history of surgeries nor accidents was
noted.

OBSTETRIC HISTORY
Aling Nena noticed her breast enlargement at 10 years old and had her first menses at
11. Her menstrual period usually lasts 5 to 7 days and she consumes about 2 to 3 pads
per day. Menstrual cycle is 28 days as noted.
In 2005, Aling Nena was a 27-year-old woman carrying her first child. Two years after,
she got pregnant with her second baby. Third baby came after 2 years- all three
pregnancies had complete prenatal check-ups (RHU), had no complications, all were full
term and delivered via normal spontaneous delivery in home birth. She also stated that
she was administered with TT1 - TT4 vaccines from her first to third pregnancy.

PRESENT ILLNESS
From the past three pregnancies, her current pregnancy has 10 years gap from her last.
Aling Nena’s last menstrual period was May 30, 2018 and then she noticed that she was
eight weeks delayed so she took a pregnancy test which yielded a positive result.
Accompanied by her husband, they sought for a prenatal checkup at RHU Quezon where
she was confirmed to be pregnant. In the assessment, her BP was 120/80mmHg, weight-
52kg, height 5’5. She undergone laboratory tests like urinalysis where no protein was
traced, CBC with APC test results were within normal range, Hbsag is non-reactive and
was given ferrous sulphate and folic acid. After that, no succeeding check-ups were done.
Two days prior to admission, Aling Nena was already experiencing dizziness and body
malaise which was relieved by rest and sleep so did not bother seeking medical
consultation.
A 41-year-old, 32 week-pregnant female patient presented in the emergency department
with chief complaints of severe nape pain (pain scale 7/10,), blurring of vision, and pain
on the right upper quadrant of the abdomen (pain scale 8/10). Vital signs upon admission
were taken as follows: T- 37 ֠ C ; PR- 95 bpm ; RR- 24 cpm ; BP- 150-100 mmHg; O2
sat- 99% ; FHT-135 bpm .
Methyldopa and paracetamol were ordered. Aling Nena was arranged for laboratory tests
such as CBC with APC, urinalysis, BUN, creatinine, and STAT orders for PPT, LDH, AST
and ALT.
After that, Aling Nena’s BP was then rechecked and 140/90 mmHg was recorded. The
physician who assessed and examined Aling Nena initially diagnosed her with G4P3
(3003) Pregnancy Uterine 32 weeks AOG, Pre-eclampsia thereby admitting the patient in
the OB Ward.
LIFESTYLE
Patient stated that her usual diet consists of fish, pork, chicken, and vegetables from their
backyard garden. She is also fond of drinking coffee consuming about 2 to 3 cups but
avoided it during her pregnancy and replaced it with milk (Bear Brand). Water intake is
approximated as 7- 8 glasses per day.
Aling Nena does not smoke nor have smoking history. Alcohol consumption was
mentioned but only on special occasions.
She stated no time for exercise and that the only physical activity she has is her usual
routine at the store.
No known allergies to medications, food and environment was reported.

FAMILY HISTORY
Aling Nena’s mother had pre-eclampsia when she delivered her fifth child(youngest). No
other incidence was noted until Aling Nena’s case.
Hypertension is present in her father’s side and 7 family members has it.

SOCIOECONOMIC HISTORY
Aling Nena earns about P6,000.00 monthly and her husband brings home P400.00 a day.